The literature relating to seven evidence linkages contained enough studies with well defined experimental designs and statistical information to conduct formal meta-analyses (table 1). Methods for confirming that the catheter is still in the venous system after catheterization and before use include manometry or pressure-waveform measurement. Ultrasonography: A novel approach to central venous cannulation. A chest x-ray will be performed immediately following thoracic central line placement to assure line placement and rule out pneumothorax. An alternative central venous route for cardiac surgery: Supraclavicular subclavian vein catheterization. A collaborative, systems-level approach to eliminating healthcare-associated MRSA, central-lineassociated bloodstream infections, ventilator-associated pneumonia, and respiratory virus infections. A multidisciplinary approach to reduce central lineassociated bloodstream infections. Refer to appendix 4 for an example of a list of duties performed by an assistant. Use the subclavian site for central lines: Compared to the internal jugular or femoral sites, the subclavian site has a lower risk of thrombosis or line infection. Simplified point-of-care ultrasound protocol to confirm central venous catheter placement: A prospective study. For femoral line CVL, the needle insertion site should be located approximately 1 to 3 cm below the inguinal ligament and 0.5 to 1 cm medial where the femoral artery pulsates. Sterility In the ED, there are only two ways to place central lines: Full Sterile or Non-Sterile There is no in-between. Prevention of central venous catheter sepsis: A prospective randomized trial. This document updates the Practice Guidelines for Central Venous Access: A Report by the American Society of Anesthesiologists Task Force on Central Venous Access, adopted by the ASA in 2011 and published in 2012.1. These updated guidelines were developed by means of a five-step process. Sometimes (hopefully rarely), the exigencies of time or patient condition will prevent placing a full sterile line. Trendelenburg position does not increase cross-sectional area of the internal jugular vein predictably. Prospective comparison of ultrasound and CXR for confirmation of central vascular catheter placement. For neonates, the consultants and ASA members agree with the recommendation to determine the use of transparent or sponge dressings containing chlorhexidine based on clinical judgment and institutional protocol. These studies were combined with 258 pre-2011 articles from the previous guidelines, resulting in a total of 542 articles accepted as evidence for these guidelines. Aiming for zero: Decreasing central line associated bacteraemia in the intensive care unit. The vessel traverses the thigh and takes a superficial course at the femoral triangle before passing beneath the inguinal ligament into the pelvis as the external iliac vein ( figure 1A-B ). Refer to appendix 5 for a summary of methods and analysis. Insert the introducer needle with negative pressure until venous blood is aspirated. For neonates, infants, and children, confirmation of venous placement may take place after the wire is threaded. Use full sterile dress. Meta-analyses of RCTs comparing antibiotic-coated with uncoated catheters indicates that antibiotic-coated catheters are associated with reduced catheter colonization7885 and catheter-related bloodstream infection (Category A1-B evidence).80,81,83,85,86 Meta-analyses of RCTs comparing silver or silver-platinum-carbonimpregnated catheters with uncoated catheters yield equivocal findings for catheter colonization (Category A1-E evidence)8797 but a decreased risk of catheter-related bloodstream infection (Category A1-B evidence).8794,9699 Meta-analyses of RCTs indicate that catheters coated with chlorhexidine and silver sulfadiazine reduce catheter colonization compared with uncoated catheters (Category A1-B evidence)83,95,100118 but are equivocal for catheter-related bloodstream infection (Category A1-E evidence).83,100102,104110,112117,119,120 Cases of anaphylactic shock are reported after placement of a catheter coated with chlorhexidine and silver sulfadiazine (Category B4-H evidence).121129. Internal jugular vein diameter in pediatric patients: Are the J-shaped guidewire diameters bigger than internal jugular vein? Catheter-Related Infections in ICU (CRI-ICU) Group. The insertion process includes catheter site selection, insertion under ultrasound guidance, catheter site dressing regimens, securement devices, and use of a CVC insertion bundle. Chlorhexidine impregnated central venous catheter inducing an anaphylatic shock in the intensive care unit. tip too high: proximal SVC. Resource preparation topics include (1) assessing the physical environment where central venous catheterization is planned to determine the feasibility of using aseptic techniques; (2) availability of a standardized equipment set; (3) use of a checklist or protocol for central venous catheter placement and maintenance; and (4) use of an assistant for central venous catheterization. A significance level of P < 0.01 was applied for analyses. There are many uses of these catheters. Methods for confirming that the catheter is still in the venous system after catheterization and before use include manometry, pressure-waveform measurement, or contrast-enhanced ultrasound. Placing the central line. Nonrandomized comparative studies indicate that longer catheterization is associated with higher catheter colonization rates, infection, and sepsis (Category B1-H evidence).21,142145 The literature is insufficient to evaluate whether time intervals between catheter site inspections are associated with the risk for catheter-related infection. Aspirate and flush all lumens and re clamp and apply lumen caps. Insert the J-curved end of the guidewire into the introducer needle, with the J curve facing up. Practice guidelines are systematically developed recommendations that assist the practitioner and patient in making decisions about health care. Of the 484 attempted placements, 472 (97.5%) were primary placements. Catheter infection risk related to the distance between insertion site and burned area. Risk factors of failure and immediate complication of subclavian vein catheterization in critically ill patients. Pacing catheters. The rate of return was 17.4% (n = 19 of 109). The consultants and ASA members strongly agree with the recommendation to use aseptic techniques (e.g., hand washing) and maximal barrier precautions (e.g., sterile gowns, sterile gloves, caps, masks covering both mouth and nose, and full-body patient drapes) in preparation for the placement of central venous catheters. The effect of process control on the incidence of central venous catheter-associated bloodstream infections and mortality in intensive care units in Mexico. Retention of antibacterial activity and bacterial colonization of antiseptic-bonded central venous catheters. The consultants agree and ASA members strongly agree with the recommendations to select an upper body insertion site to minimize the risk of thrombotic complications relative to the femoral site. The procedure to place a femoral central line is as follows: You will have to lie down on your back for this procedure. Survey Findings. New York State Regional Perinatal Care Centers. Literature Findings. The femoral vein is the major deep vein of the lower extremity. Confirmation of internal jugular guide wire position utilizing transesophageal echocardiography. Case reports of adult patients with arterial puncture by a large-bore catheter/vessel dilator during attempted central venous catheterization indicate severe complications (e.g., cerebral infarction, arteriovenous fistula, hemothorax) after immediate catheter removal (Category B4-H evidence)172,176,253; complications are uncommonly reported for adult patients whose catheters were left in place before surgical consultation and repair (Category B4-E evidence).172,176,254. Please read and accept the terms and conditions and check the box to generate a sharing link. Evidence was obtained from two principal sources: scientific evidence and opinion-based evidence. Cardiac tamponade associated with a multilumen central venous catheter. Methods for confirming that the catheter or thin-wall needle resides in the vein include, but are not limited to, ultrasound, manometry, or pressure-waveform analysis measurement. Does ultrasound imaging before puncture facilitate internal jugular vein cannulation? Contamination of central venous catheters in immunocompromised patients: A comparison between two different types of central venous catheters. The variation between the two techniques reflects mitigation steps for the risk that the thin-wall needle in the Seldinger technique could move out of the vein and into the wall of an artery between the manometry step and the threading of the wire step. Central venous access: The effects of approach, position, and head rotation on internal jugular vein cross-sectional area. Heterogeneity was quantified with I2 and prediction intervals estimated (see table 1). Central vascular catheter placement evaluation using saline flush and bedside echocardiography. A minimum of five independent RCTs (i.e., sufficient for fitting a random-effects model255) is required for meta-analysis. (Co-Chair), Seattle, Washington; Avery Tung, M.D. Incidence of mechanical complications of central venous catheterization using landmark technique: Do not try more than 3 times. Impregnated central venous catheters for prevention of bloodstream infection in children (the CATCH trial): A randomised controlled trial. Objective To investigate the efficacy of the minimally invasive clamp reduction technique via the anterior approach in the treatment of irreducible intertrochanteric femoral fractures. Category A: RCTs report comparative findings between clinical interventions for specified outcomes. These values represented moderate to high levels of agreement. Iatrogenic injury of vertebral artery resulting in stroke after central venous line insertion. National Association of Childrens Hospitals and Related Institutions Pediatric Intensive Care Unit Central LineAssociated Bloodstream Infection Quality Transformation Teams. Preparation of these updated guidelines followed a rigorous methodological process. Level 4: The literature contains case reports. **, Comparative studies are insufficient to evaluate the efficacy of chlorhexidine and alcohol compared with chlorhexidine without alcohol for skin preparation during central venous catheterization. (Committee Chair), Chicago, Illinois; Stephen M. Rupp, M.D. RCTs report equivocal findings for successful venipuncture when the internal jugular site is compared with the subclavian site (Category A2-E evidence).131,155,156 Equivocal finding are also reported for the femoral versus subclavian site (Category A2-E evidence),130,131 and the femoral versus internal jugular site (Category A3-E evidence).131 RCTs examining mechanical complications (primarily arterial injury, hematoma, and pneumothorax) report equivocal findings for the femoral versus subclavian site (Category A2-E evidence)130,131 as well as the internal jugular versus subclavian or femoral sites (Category A3-E evidence).131. COPD, chronic obstructive pulmonary disease; CPR, cardiopulmonary resuscitation; ECG, electrocardiography; IJ, internal jugular; PA, pulmonary artery; TEE, transesophageal echocardiography. Submitted for publication March 15, 2019. Impact of a prevention strategy targeted at vascular-access care on incidence of infections acquired in intensive care. Failure of antiseptic bonding to prevent central venous catheter-related infection and sepsis. Mark, M.D., Durham, North Carolina. Images in cardiovascular medicine: Percutaneous retrieval of a lost guidewire that caused cardiac tamponade. An RCT of 5% povidoneiodine with 70% alcohol compared with 10% povidoneiodine alone indicates that catheter tip colonization is reduced with alcohol containing solutions (Category A3-B evidence); equivocal findings are reported for catheter-related bloodstream infection and clinical signs of infection (Category A3-E evidence).77. The consultants and ASA members agree that needleless catheter access ports may be used on a case-by-case basis, Do not routinely administer intravenous antibiotic prophylaxis, In preparation for the placement of central venous catheters, use aseptic techniques (e.g., hand washing) and maximal barrier precautions (e.g., sterile gowns, sterile gloves, caps, masks covering both mouth and nose, full-body patient drapes, and eye protection), Use a chlorhexidine-containing solution for skin preparation in adults, infants, and children, For neonates, determine the use of chlorhexidine-containing solutions for skin preparation based on clinical judgment and institutional protocol, If there is a contraindication to chlorhexidine, povidoneiodine or alcohol may be used, Unless contraindicated, use skin preparation solutions containing alcohol, For selected patients, use catheters coated with antibiotics, a combination of chlorhexidine and silver sulfadiazine, or silver-platinum-carbonimpregnated catheters based on risk of infection and anticipated duration of catheter use, Do not use catheters containing antimicrobial agents as a substitute for additional infection precautions, Determine catheter insertion site selection based on clinical need, Select an insertion site that is not contaminated or potentially contaminated (e.g., burned or infected skin, inguinal area, adjacent to tracheostomy or open surgical wound), In adults, select an upper body insertion site when possible to minimize the risk of infection, Determine the use of sutures, staples, or tape for catheter fixation on a local or institutional basis, Minimize the number of needle punctures of the skin, Use transparent bioocclusive dressings to protect the site of central venous catheter insertion from infection, Unless contraindicated, dressings containing chlorhexidine may be used in adults, infants, and children, For neonates, determine the use of transparent or sponge dressings containing chlorhexidine based on clinical judgment and institutional protocol, If a chlorhexidine-containing dressing is used, observe the site daily for signs of irritation, allergy, or necrosis, Determine the duration of catheterization based on clinical need, Assess the clinical need for keeping the catheter in place on a daily basis, Remove catheters promptly when no longer deemed clinically necessary, Inspect the catheter insertion site daily for signs of infection, Change or remove the catheter when catheter insertion site infection is suspected, When a catheter-related infection is suspected, a new insertion site may be used for catheter replacement rather than changing the catheter over a guidewire, Clean catheter access ports with an appropriate antiseptic (e.g., alcohol) before each access when using an existing central venous catheter for injection or aspiration, Cap central venous catheter stopcocks or access ports when not in use, Needleless catheter access ports may be used on a case-by-case basis. Citation searching (backward and forward) of relevant meta-analyses and other systematic reviews was also performed; pre-2011 studies relevant to meta-analyses or use of ultrasound were eligible for inclusion. Chlorhexidine and gauze and tape dressings for central venous catheters: A randomized clinical trial. Third, consultants who had expertise or interest in central venous catheterization and who practiced or worked in various settings (e.g., private and academic practice) were asked to participate in opinion surveys addressing the appropriateness, completeness, and feasibility of implementation of the draft recommendations and to review and comment on a draft of the guidelines. Guidance for needle, wire, and catheter placement includes (1) real-time or dynamic ultrasound for vessel localization and guiding the needle to its intended venous location and (2) static ultrasound imaging for the purpose of prepuncture vessel localization. The epidemiology, antibiograms and predictors of mortality among critically-ill patients with central lineassociated bloodstream infections. 1), After insertion of a catheter that went over the needle or a thin-wall needle, confirm venous access, If there is any uncertainty that the catheter or wire resides in the vein, confirm venous residence of the wire after the wire is threaded; insertion of a dilator or large-bore catheter may then proceed, After final catheterization and before use, confirm residence of the catheter in the venous system as soon as clinically appropriate####, Confirm the final position of the catheter tip as soon as clinically appropriate*****, Example of a Standardized Equipment Cart for Central Venous Catheterization for Adult Patients. Chlorhexidine-impregnated dressings and prevention of catheter-associated bloodstream infections in a pediatric intensive care unit. Catheter-related infection and thrombosis of the internal jugular vein in hematologic-oncologic patients undergoing chemotherapy: A prospective comparison of silver-coated and uncoated catheters. Central venous catheter colonization and catheter-related bloodstream infections in critically ill patients: A comparison between standard and silver-integrated catheters. Do not force the wire; it should slide smoothly. Pediatric Patients: o Optimal catheter type and site selection in children is more co mplex, with the internal jugular vein or femoral vein most commonly used. A multicenter intervention to prevent catheter-associated bloodstream infections. A central venous catheter, also called a central line or CVC, is a device that helps you receive treatments for various medical conditions. Impact of a national multimodal intervention to prevent catheter-related bloodstream infection in the ICU: The Spanish experience. Monitoring central line pressure waveforms and pressures. Confirmation of endovenous placement of central catheter using the ultrasonographic bubble test., The use of ultrasound during and after central venous catheter insertion. Survey Findings. No search for gray literature was conducted. : Prospective randomized comparison with landmark-guided puncture in ventilated patients. Comparison of triple-lumen central venous catheters impregnated with silver nanoparticles (AgTive). Time-series analysis to observe the impact of a centrally organized educational intervention on the prevention of central-lineassociated bloodstream infections in 32 German intensive care units. Inadvertent prolonged cannulation of the carotid artery. Efficacy of silver-coating central venous catheters in reducing bacterial colonization. Literature exclusion criteria (except to obtain new citations): For the systematic review, potentially relevant clinical studies were identified via electronic and manual searches. This line is placed in a large vein in the groin. RCTs comparing subclavian and femoral insertion sites report that the femoral site has a higher risk of thrombotic complications in adult patients (Category A2-H evidence)130,131; one RCT131 concludes that thrombosis risk is higher with internal jugular than subclavian catheters (Category A3-H evidence), whereas for femoral versus internal jugular catheters, findings are equivocal (Category A3-E evidence). The consultants agree and ASA members strongly agree that the number of insertion attempts should be based on clinical judgment and that the decision to place two catheters in a single vein should be made on a case-by-case basis. Ultrasound-guided supraclavicular central venous catheter tip positioning via the right subclavian vein using a microconvex probe. In this document, only the highest level of evidence is included in the summary report for each interventionoutcome pair, including a directional designation of benefit, harm, or equivocality. Central venous catheters coated with minocycline and rifampin for the prevention of catheter-related colonization and bloodstream infections: A randomized, double-blind trial. Multidisciplinary trauma intensive care unit checklist: Impact on infection rates. For studies that report statistical findings, the threshold for significance is P < 0.01. A randomized trial comparing povidoneiodine to a chlorhexidine gluconate-impregnated dressing for prevention of central venous catheter infections in neonates. The impact of a quality improvement intervention to reduce nosocomial infections in a PICU. Survey responses were recorded using a 5-point scale and summarized based on median values., Strongly agree: Median score of 5 (at least 50% of the responses are 5), Agree: Median score of 4 (at least 50% of the responses are 4 or 4 and 5), Equivocal: Median score of 3 (at least 50% of the responses are 3, or no other response category or combination of similar categories contain at least 50% of the responses), Disagree: Median score of 2 (at least 50% of responses are 2 or 1 and 2), Strongly disagree: Median score of 1 (at least 50% of responses are 1), The rate of return for the survey addressing guideline recommendations was 37% (n = 40 of 109) for consultants. Elective central venous access procedures, Emergency central venous access procedures, Any setting where elective central venous access procedures are performed, Providers working under the direction of anesthesiologists, Individuals who do not perform central venous catheterization, Selection of a sterile environment (e.g., operating room) for elective central venous catheterization, Availability of a standardized equipment set (e.g., kit/cart/set of tools) for central venous catheterization, Use of a trained assistant for central venous catheterization, Use of a checklist for central venous catheter placement and maintenance, Washing hands immediately before placement, Sterile gown, gloves, mask, cap for the operators, Shaving hair versus clipping hair versus no hair removal, Skin preparation with versus without alcohol, Antibiotic-coated catheters versus no coating, Silver-impregnated catheters versus no coating, Heparin-coated catheters versus no coating, Antibiotic-coated or silver-impregnated catheter cuffs, Selecting an insertion site that is not contaminated or potentially contaminated (e.g., burned or infected skin, a site adjacent to a tracheostomy site), Long-term versus short-term catheterization, Frequency of assessing the necessity of retaining access, Frequency of insertion site inspection for signs of infection, At specified time intervals versus no specified time intervals, One specified time interval versus another time interval, Changing over a wire versus a new catheter at a new site, Injecting or aspirating using an existing central venous catheter, Aseptic techniques (e.g., wiping port with alcohol). The consultants and ASA members agree that when feasible, real-time ultrasound may be used when the subclavian or femoral vein is selected. The consultants and ASA members both strongly agree with the recommendation to minimize the number of needle punctures of the skin. 2012 Emery A. Rovenstine Memorial Lecture: The genesis, development, and future of the American Society of Anesthesiologists evidence-based practice parameters. The literature is insufficient to evaluate the efficacy of transparent bioocclusive dressings to reduce the risk of infection. Use of ultrasound to evaluate internal jugular vein anatomy and to facilitate central venous cannulation in paediatric patients. The consultants and ASA members strongly agree with the recommendation to confirm venous residence of the wire after the wire is threaded if there is any uncertainty that the catheter or wire resides in the vein, and insertion of a dilator or large-bore catheter may then proceed. Opinion surveys were developed by the task force to address each clinical intervention identified in the document. hemorrhage, hematoma formation, and pneumothorax during central line placement. Fifth, all available information was used to build consensus to finalize the guidelines. Reduced intravascular catheter infection by antibiotic bonding: A prospective, randomized, controlled trial. Comparison of bacterial colonization rates of antiseptic impregnated and pure polymer central venous catheters in the critically ill. A comparison between two types of central venous catheters in the prevention of catheter-related infections: The importance of performing all the relevant cultures. The long-term effect of bundle care for catheter-related blood stream infection: 5-year follow-up. Central venous line placement is typically performed at four sites in the body: . All meta-analyses are conducted by the ASA methodology group. Cerebral infarct following central venous cannulation. The needle was exchanged over the wire for an arterial . Trendelenburg position, head elevation and a midline position optimize right internal jugular vein diameter. Insert the J-curved end of the guidewire into the introducer needle, with the J curve facing up. The literature is insufficient to evaluate the effect of the physical environment for aseptic catheter insertion, availability of a standardized equipment set, or the use of an assistant on outcomes associated with central venous catheterization. The American Society of Anesthesiologists practice parameter methodology. Within the text of these guidelines, literature classifications are reported for each intervention using the following: Category A level 1, meta-analysis of randomized controlled trials (RCTs); Category A level 2, multiple RCTs; Category A level 3, a single RCT; Category B level 1, nonrandomized studies with group comparisons; Category B level 2, nonrandomized studies with associative findings; Category B level 3, nonrandomized studies with descriptive findings; and Category B level 4, case series or case reports. Reduction of catheter-related bloodstream infections through the use of a central venous line bundle: Epidemiologic and economic consequences. If you feel any resistance as you advance the guidewire, stop advancing it. Fourth, additional opinions were solicited from random samples of active ASA members. Prevention of catheter-related bloodstream infection in critically ill patients using a disinfectable, needle-free connector: A randomized controlled trial. Ideally the distal end of a CVC should be orientated vertically within the SVC. The long-term impact of a program to prevent central lineassociated bloodstream infections in a surgical intensive care unit. Central venous line sepsis in the intensive care unit: A study comparing antibiotic coated catheters with plain catheters. Four hundred eighty-one (99.4%) placements were technically successful. Aseptic insertion of central venous lines to reduce bacteraemia: The central line associated bacteraemia in NSW intensive care units (CLAB ICU) collaborative. Survey Findings. Direct URL citations appear in the printed text and are available in both the HTML and PDF versions of this article. Influence of triple-lumen central venous catheters coated with chlorhexidine and silver sulfadiazine on the incidence of catheter-related bacteremia. Using the comprehensive unit-based safety program model for sustained reduction in hospital infections. Advance the guidewire through the needle and into the vein. Refer to appendix 2 for an example of a list of standardized equipment for adult patients. Evidence categories refer specifically to the strength and quality of the research design of the studies. Survey Findings. Central Line Insertion Care Team Checklist. The literature is insufficient to evaluate outcomes associated with the routine use of intravenous prophylactic antibiotics. Methods for confirming the position of the catheter tip include chest radiography, fluoroscopy, or point-of-care transthoracic echocardiography or continuous electrocardiography. Survey Findings. Address correspondence to the American Society of Anesthesiologists: 1061 American Lane, Schaumburg, Illinois 60173.
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